Rapid Decrease in Fluoroquinolones Consumption following Implementation of a Simple Antimicrobial Stewardship Bundled Intervention in a University Hospital during the COVID-19 Pandemic.

Fluoroquinolones (FQs) represent an class of antibiotics of medical importance, but their use has been restricted due to their ecologic impact and associated side effects. The reduction of FQs use is an important goal of antimicrobial stewardship programs (ASP). This work describes an ASP focused on overall antibiotics and FQs consumption reduction. From January 2021, an ASP was implemented in a 700-bed teaching hospital. The ASP was based on: (i) antibiotics consumption monitoring system (DDD/100 bed days); (ii) mandatory antibiotic prescription-motivation (using a dedicated informatic format) with the goal of >75% of motivated prescriptions; and (iii) data feedback and training on FQs use indications. We evaluated the impact of the intervention on overall systemic antibiotics and FQs consumption according to the objectives posed by Italian PNCAR (National Action Plan on Antimicrobial Resistance). A decrease of 6.6% in antibiotic use was observed (2019 vs. 2021). Notably, the FQs consumption fell by 48.3% from 7.1 DDD/100 bd in 2019 to 3.7 DDD/100 bd in 2021 (p < 0.001). After six months of mandatory antibiotic prescription-indication, all units achieved the target set. The study suggests that a simple, bundled ASP intervention can be rapidly effective obtaining the objectives of PNCAR on the reduction of overall antibiotics and FQs consumption.

Ground level utility of Access, Watch, Reserve classification: Insights from a tertiary care center in North India.

BACKGROUND: The overuse and misuse of antimicrobials contribute significantly to antimicrobial resistance (AMR), which is a global public health concern. India has particularly high rates of AMR, posing a threat to effective treatment. The World Health Organization (WHO) Access, Watch, Reserve (AWaRe) classification system was introduced to address this issue and guide appropriate antibiotic prescribing. However, there is a lack of studies examining the prescribing patterns of antimicrobials using the AWaRe classification, especially in North India. Therefore, this study aimed to assess the prescribing patterns of antimicrobials using the WHO AWaRe classification in a tertiary care centre in North India. AIM: To study the prescribing patterns of antimicrobials using WHO AWaRe classification through a cross-sectional study in All India Institute of Medical Sciences Rishikesh. METHODS: A descriptive, cross-sectional study was conducted from July 2022 to August 2022 at a tertiary care hospital. Prescriptions containing at least one antimicrobial were included in the study. Data on prescriptions, including patient demographics, departments, types of antimicrobials prescribed, and duration of treatment, were collected. A questionnaire-based survey was also conducted to assess the knowledge and practices of prescribing doctors regarding the utility of AWaRe classification. RESULTS: The study involved a total of 123 patients, each of whom received at least one antimicrobial prescription. Most prescriptions were for inpatients, evenly distributed between Medicine (Internal medicine, Pediatrics, Dermatology) and Surgical departments (General surgery and specialties, Otorhinolaryngology, Ophthalmology, Obstetrics and Gynecology). Metronidazole and ceftriaxone were the most prescribed antibiotics. According to the AWaRe classification, 57.61% of antibiotics fell under the Access category, 38.27% in Watch, and 4.11% in Reserve. Most Access antibiotics were prescribed within the Medicine department, and the same department also exhibited a higher frequency of Watch antibiotics prescriptions. The questionnaire survey showed that only a third of participants were aware of the AWaRe classification, and there was a lack of knowledge regarding AMR and the potential impact of AWaRe usage. CONCLUSION: This study highlights the need for better antimicrobial prescribing practices and increased awareness of the WHO AWaRe classification and AMR among healthcare professionals. The findings indicate a high proportion of prescriptions falling under the Access category, suggesting appropriate antibiotic selection. However, there is a significant difference between the WHO Defined Daily Dose and the prescribed daily dose in the analysed prescriptions suggesting overuse and underuse of antibiotics. There is room for improvement and educational interventions and antimicrobial stewardship programs should be implemented to enhance knowledge and adherence to guidelines, ultimately contributing to the containment of AMR.

Hypertension outcomes of adrenalectomy for unilateral primary aldosteronism.

PURPOSE: To evaluate laboratory and clinical results after unilateral adrenalectomy in patients with primary aldosteronism (PHA). METHODS: A cross-sectional analysis was performed using data from patients who underwent transperitoneal laparoscopic adrenalectomy for PHA, between January 2008 and December 2019. Surgical indications were based on adrenal venous sampling without ACTH stimulation. Analyses included patient demographics; preoperative clinical, pharmacological, laboratory, and radiological data; and postoperative results assessed after a median of 4 months. Antihypertensive drug use was quantified by estimating the daily defined dose (DDD) of antihypertensive medication, thus enabling standardized comparison of dosage between the drug classes. Statistical assessments included univariable and multivariable logistic regression analysis. RESULTS: This study enrolled 87 patients. The patients were taking 5.4 DDD of antihypertensive medication before surgery, and 3.0 DDD after surgery. Complete biochemical success of surgery was reached 67 patients (77%), 19 patients (22%) had partial biochemical success. Complete clinical success with normalization of blood pressure and withdrawal of all antihypertensive drugs was achieved in 19 patients (22%). 57 patients (65%) exhibited a reduction of DDD after surgery and/or improvement of blood pressure-partial clinical success. Thus, in 76 (87%) of all enrolled patients, surgery had an overall positive effect on hypertension control. Multivariable logistic regression showed that complete clinical success was independently associated with female gender and baseline sum of antihypertensive drugs DDD < 4. CONCLUSION: A majority of patients undergoing unilateral adrenalectomy for PHA achieved markedly improved hypertension control, despite almost halving their antihypertensive medication. Almost a quarter of patients were cured and able to cease using all antihypertensive drugs.

Drug Utilization Study of Antidiabetic Drugs in Patients Attending Geriatric Outpatient Department at a Tertiary Care Hospital.

Introduction Diabetes has increased in prevalence from 108 million individuals in 1980 to 463 million individuals in 2021. As people's life expectancies have risen, it's become increasingly necessary to be worried about diseases that affect the elderly. To focus and manage these diseases effectively, the illumination of current knowledge about the pattern of anti-diabetic drug utilization in the elderly is important. As a result, it is necessary to evaluate the pattern of anti-diabetic medication use among diabetes patients of the geriatric age group and determine if there is room for improvement in light of current knowledge. With this information, we intend to provide feedback and suggestions for the health care providers. This research aimed to study and analyze the drug utilization of antidiabetic medications in patients attending the geriatric outpatient department. Methods The data of 600 patients visiting the geriatric outpatient department from January 1, 2016 to September 30, 2017 were collected from the electronic medical record (EMR) database. The protocol was designed using Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Subjects were grouped according to gender, age, drug combination use, and underlying co-morbidities. Indicators of drug usage and the total number of drugs prescribed and prescription patterns were analyzed. Then, the recorded data were classified according to the anatomical therapeutic chemical (ATC) - daily defined dose (DDD) classification. Prescribed daily dose (PDD) values and PDD/DDD ratio of antidiabetic drugs prescribed to a sample of patients (n=600) were calculated. Cost analysis of the prescribed drugs was analyzed and the cost index for each drug is described. Results A total of 600 diabetic patients (286 males) were recruited in the study. In the study, the average age of participants was 69.30±11.34 years. The most common comorbidity associated with diabetes mellitus (DM) was hypertension followed by hypertension along with chronic heart disease. Glibenclamide and pioglitazone (thiazolidenediones) had PDD/DDD ratio equal to 1. The ratios for glimepiride (sulfonylurea), metformin (biguanides), sitagliptin (sodium-glucose cotransporter 2 inhibitor), insulin glargine, insulin lispro, insulin aspart, were 1.85, 1.29, 1.66, 1.63, 1.42, and 1.21, respectively, whereas the premixed insulin had a ratio of 0.83. The average cost per prescription was USD 3.36 and around 87.72% of the cost per prescription was due to the prescribed antidiabetics. Metformin + glibenclamide was the most commonly prescribed combination followed by metformin + glimepiride. Conclusion On the whole, the principles of rational prescription were followed in accordance with the different WHO drug usage indicators. Many of the drugs prescribed by generic name were supplied from hospital pharmacy thus reducing the burden to some extent.

Post-Diagnostic Statin Use Reduces Mortality in South Korean Patients with Dyslipidemia and Gastrointestinal Cancer.

BACKGROUND: Statins play a role in lowering serum cholesterol and are known to have pleiotropic effects in a variety of diseases, including cancer. Despite the beneficial effects of statins in dyslipidemia patients, the treatment rate for dyslipidemia in Korea remains low, and evidence supporting the continued use of statins is lacking. The purpose of this study was to evaluate the effect of continued statin use and dosage on patient mortality after diagnosis of dyslipidemia and gastrointestinal (GI) cancer. METHODS: We used data from the National Health Insurance Sampling (NHIS) cohort to evaluate patients diagnosed with dyslipidemia from 2002 to 2015. A total of 901 GI cancer patients with dyslipidemia and 62,727 non-cancer dyslipidemia patients were included in the study. During the study period, each patient's medication possession ratio (MPR) after diagnosis was evaluated as a measure of continued statin use. Statin dosage was measured based on a defined daily dose (DDD). Finally, we used Cox-proportional hazard ratios to identify associations between the continual use of statins and mortality in patients with dyslipidemia and GI cancer. RESULTS: In our study, mortality decreased with increasing MPR and reached significance in MPRs exceeding 50% for GI cancer patients and 75% for dyslipidemia patients compared to patients that did not use statins. Moreover, patients with high MPRs had significantly reduced 5-year mortality compared to non-users, and cause-specific mortality analyses revealed that high MPR was associated with decreased colorectal cancer death. We did not find a significant dose-response relationship between statins and mortality. CONCLUSION: Our findings suggest that continued statin use after diagnosis is associated with reduced patient mortality. Altogether, these results support the continued use of statins in dyslipidemia patients with and without GI cancer and highlight the importance of patient education by healthcare providers.

Orthostatic blood pressure drop and cardiovascular and psychotropic medication dosages in acutely ill geriatric inpatients.

OBJECTIVES: . To investigate the dose-response relationship between cardiovascular or psychotropic medication dosages and falling orthostatic blood pressure in geriatric inpatients. METHODS: . This cross-sectional study included 100 consecutive geriatric inpatients of a Belgian hospital. The end points were the maximum changes of systolic (sBP) and diastolic (dBP) blood pressure in a standing up position at one or three minutes. The dosages of six classes of vascular and five classes of psychotropic medications were expressed in terms of a proportion of defined daily doses (DDD). Bivariate and multivariate linear regression models were used. RESULTS: . The 100 geriatric patients (85 ± 5 years, 58 % women) received 7.7 ± 4 medications (mean DDD: vascular = 1.0, psychotropic = 0.74) on the day of an orthostatic test (lying sBP: 136 ± 21; dBP: 72 ± 14 mm Hg). In a standing position, sBP and dBP fell by 12 ± 17 and 11 ± 5 mmHg, respectively. At the individual level, BP change was not correlated with vascular DDD (sBP: p = 0.07, r2 = 0.04; dBP: p = 0.59; r2 = 0.004) nor with psychotropic DDD (sBP: p = 0.14, r2 = 0.02; dBP: p = 0.82; r2 = 0.0). In multivariate analysis, sBP drop was positively associated with age, diabetes, falls history, and number of medications, but not with the DDD of any of the medication classes, while dBP drop was positively associated with age, diabetes, stroke and anaemia, but again with the DDD of any of the medication classes. CONCLUSION: . No correlation was found between vascular and psychotropic medication dosages and the orthostatic blood pressure drop expressed as a continuous variable.

The burden of chronic noncommunicable diseases in undocumented migrants: a 1-year survey of drugs dispensation by a non-governmental organization in Italy.

OBJECTIVES: This study was carried out with two objectives. The first one was to have an insight into the prevalence of chronic noncommunicable diseases (CNCD) in undocumented migrants, and the second one was to evaluate if differences existed among different ethnic groups. STUDY DESIGN: The study is based on the collection of data on drug dispensation by a non-governmental organization (NGO) providing free medical assistance to undocumented migrants in Milan, Italy. All the prescriptions to adult subjects from January 1 to December 31 2014 (total 8438) were recorded and analyzed. All the data available for the patients receiving prescriptions (age, gender and country of birth) were also collected in anonymous form. Ethical approval for the study was given by the Ethics Committee of the NGO. METHODS: Drugs were grouped according to the anatomical therapeutic chemical (ATC) classification and their quantities expressed as daily defined doses (DDDs)/1000 patients/day. The 56 ATC levels were divided into three groups according to their use for acute, chronic, or both acute and chronic diseases. The statistical analysis of drug dispensation was performed for the whole population and for the five ethnic groups into which it had been divided. RESULTS: Prescription of medicines for chronic conditions was significantly greater than for acute (154.2 ± 45.9 vs 51.3 ± 18.4 DDD/1000 patients/day, P < 0.02) and for both acute and chronic conditions (57.9 ± 12.8 DDD/1000 patients/day, P < 0.02). Five ATC classes accounted for 60% of all chronic prescriptions. They were differently distributed among the five ethnic groups (e.g., Asians required more antihypertensives and antidiabetics, East Europeans required more lipid modifying drugs, antihypertensives and antithrombotics). CONCLUSIONS: Our data show an important use of medicines for chronic diseases in a population of undocumented migrants. Though with some limitations, this could be an indicator of a high prevalence of CNCD in this population, with significant differences among different ethnic groups. This situation should be considered when planning health interventions, also in consideration of the fact that it could have an impact on European Health Services in a short time.

Measuring drug exposure: concordance between defined daily dose and days' supply depended on drug class.

OBJECTIVES: To determine the concordance between two methods to measure drug exposure duration from pharmacy claim data. STUDY DESIGN AND SETTING: We conducted a cohort study using 2002-2007 US Medicaid data. Initiators of eight drug groups were identified: statins, metformin, atypical antipsychotics, warfarin, proton pump inhibitors (PPIs), angiotensin-converting enzyme (ACE) inhibitors, nonsteroidal anti-inflammatory drugs (ns-NSAIDs), and coxibs. For each patient, we calculated two measures of exposure duration using (1) observed days' supply available in US pharmacy claims and (2) the World Health Organisation's Defined Daily Dose (DDD) methodology. We used Wilcoxon signed rank tests to compare medians and Spearman correlations to assess correlation between the two measures. RESULTS: Cohort sizes ranged from 143,885 warfarin users to >3,000,000 ns-NSAID users. Similar median exposure durations were observed for ACE inhibitors (70 days vs.75 days), PPIs (44 days vs. 45 days), and coxibs (44 days vs. 45 days). The DDD method overestimated exposure duration for ns-NSAIDs and underestimated for the remaining drug groups, relative to days' supply. Spearman correlation coefficients ranged from 0.2 to 0.8. CONCLUSION: Using DDDs to estimate drug exposure duration can result in misclassification. The magnitude of this misclassification might depend on doses used which can vary according to factors such as local prescribing practices, renal function, and age.

Prescription opioid analgesics for pain management in Australia: 20 years of dispensing.

BACKGROUND: Opioid prescribing/dispensing data can inform policy surrounding regulation by informing trends and types of opioid prescribed and geographic variations. In Australia so far only partial data on dispensing have been published, and data for states/territories remain unknown. AIM: Using a range of measures, this study examines 20-year (1992-2011) trends in prescription opioid analgesics in Australia - both nationally and for individual jurisdictions. METHODS: Dispensing data were obtained from the Drug Utilisation Sub-Committee and the Pharmaceutical Benefits Scheme (PBS) websites. Trends in numbers of prescriptions and daily defined dose (DDD)/1000 people/day were examined over time and across states/territories. Seasonal variations in PBS/Repatriation Pharmaceutical Benefits Scheme (RPBS) items for nationwide dispensing were adjusted using a centred moving smoothing technique. RESULTS: In two decades, 165.32 million prescriptions for opioids were dispensed, with codeine and its derivatives the most prescribed formulation (50.1%) followed by tramadol (13.5%) and oxycodone derivatives (12.7%). In terms of DDD/1000 people/day, dispensing increased from 5.38 in 1992 to 14.46 in 2011. There are significant increasing trends for total, PBS/RPBS and under co-payment prescriptions (priced below patient co-payment). The DDD/1000 people/day for items dispensed through PBS/RPBS was highest in Tasmania. CONCLUSION: Prescription opioid dispensing increased substantially over the study period. With an ageing population, this trend is likely to continue in future. A growing concern about harms associated with opioid use warrants balanced control measures so that harms could be minimised without reducing effective pain treatment. Research examining utilisation in small geographic areas may help design spatially tailored interventions. A real-time drug-monitoring programme may reduce undue prescribing and dispensing.

Reserve drug indent form and its impact on antimicrobial consumption and sensitivity pattern in the medical intensive care unit of a tertiary care hospital.

OBJECTIVES: A world without effective antibiotics is a terrifying but a real prospect. Overuse or misuse especially of newer and higher antimicrobials (AM) is of particular concern, as this contributes to development of resistance among microorganisms. To check this trend, the Reserve Drug Indent Form (RDIF) was introduced in our hospital and its impact on AM consumption, cost of therapy and the sensitivity pattern was studied in the medical intensive care unit (MICU). MATERIALS AND METHODS: A retrospective descriptive study in the medical ICU of a tertiary care hospital from July 2012 to August 2013. From March 2013, RDIF was made mandatory to be filled up prior to prescribing reserve antimicrobials. AM consumption (expressed as DDD/100 bed days) and sensitivity pattern (expressed in percentage) six months prior to and six months after implementation of the form were analysed. RESULTS: The total Reserve AM consumption was 125.79 per 100 bed days during the study period. Average occupancy index was 0.50 and length of ICU stay was 6 days. The total consumption reduced from 85.55/100 to 40.24/100 bed days after the introduction of the RDIF. However, Imipenem usage increased from 11.35/100 to 23.94/100 bed days, which can be attributed to sensitivity profile to Imipenem (82.1%) compared to Meropenem (65.7%). Cost of therapy reduced from Rs 6,27,951 to 4,20,469. CONCLUSION: Reserve AM consumption showed a declining trend after introduction of the RDIF. Hence, the RDIF served as an important tool to combat inappropriate use, reducing the cost burden and also helped to improve the sensitivity to reserve drugs.

A drug utilization study of cognition enhancers in dementia in a tertiary care hospital in mumbai.

BACKGROUND: Cognitive decline is one of the important factors undermining the quality of life in geriatric patients. Although the WHO has declared 'Dementia' as a priority health condition.Cognitive neuropharmacology is still in its infancy and there is no general consensus on the use of cognition enhancing (CE) drugs in humans. Since drug utilization data of CEs in dementia are scarce, we conducted a study to describe the observed patterns of CE drug use, compare it to the current recommendations and conduct a preliminary cost analysis. METHODS: A prospective cross sectional drug utilization study of 100 prescriptions of patients of both sexes and all ages suffering from dementia attending the Neurology and Psychiatry clinics was undertaken as per the WHO - DUS and the STROBE guidelines. RESULTS: In all, the 100 prescriptions contained 322 drugs, out of which, 168 were CE drugs. 38.2% of the drugs were prescribed by generic names. Donepezil, Memantine, Piracetam, Rivastigmine and Gallantamine were prescribed to 76%, 34%, 8%, 6% and 0%, respectively. The PDD/DDD ratio of Donepezil and Memantine were 1.36 and 0.94, respectively. The average cost per prescription was INR 626.29 or USD 9.5. CONCLUSION: Principles of rational prescribing were followed. Donepezil and Memantine were the most commonly prescribed drugs and hence should be included in the hospital drug schedule. Piracetam should not be prescribed because of doubtful benefits and high cost. Antipsychotics should be used in geriatric dementia patients very judiciously. A major part of the total cost per prescription was borne by the patient.

Sociodemographic factors influencing the use of injections in South Korean outpatient care.

PURPOSE: This study explored the relationship between sociodemographic factors and injection utilization in South Korea. METHODS: We conducted a retrospective cross-sectional analysis using 2009 prescription claims for Korean National Health Insurance beneficiaries. We analyzed the utilization, costs, and proportion of injections in the insured market for oral-injection dual-dose-form ingredients (DFIs). We included outpatients who were prescribed DFIs with no age limits. Descriptive analysis and multivariate logistic regression were performed to evaluate the predictive factors of injection use. RESULTS: Injections accounted for about 5% of outpatient utilization and costs of the study drugs. The odds of having injections were 1.3-1.6 times higher among those patients who are 70 years and older compared with those in the 20s, in smaller-sized hospitals and clinics than that in larger, and among medical institutions in rural areas than those in the capital area. The odds of having injections were increased stepwise for the age groups of 30-69 years. Injections were more likely to be prescribed for systematic hormonal preparations and drugs for the musculoskeletal system. CONCLUSIONS: The use of injections was higher among older groups, among smaller medical institutions, and among institutions in rural areas in Korean outpatient care. The difference between prescribing defined daily doses and prescribing rate for injections of the audit reports implies that Korean doctors prescribed injections often, but small doses for momentary effects in outpatient settings. Further studies are required to uncover the underlying causes of the high prevalence of injection use in older or rural populations and smaller institutions.

The Changing Patterns of Antibiotics Usage in Korea during 1981-2008 / 감염과화학요법

BACKGROUND: The actual trends in antibiotic use in Korea are difficult to determine because antibiotic usage, which is not covered by insurance or not consumed in all hospitals in Korea, cannot be calculated accurately. Therefore, this study estimated the antibiotic usage indirectly from the data available in the 'Annual Products of Medicine,' which is published by the Korean Pharmaceutical Manufacturers Association. MATERIALS AND METHODS: The data from 'Annual Products of Medicine in 2008' was analyzed. The cost and amounts of antibiotics produced were calculated and compared with previous data. RESULTS: In 2008, the total cost of antibiotics was $ 1.6 billion, and the total amount was 1,140 tons. Since 1993, there has been an upward trend in the total amount of antibiotics produced. In contrast, there has been a downward trend in the proportion of antibiotics among all pharmacological agents produced. In terms of the amount, the production of cephalosporins was highest since 2003, whereas the production of penicillins was highest before 2003. The production of third and fourth generation cephalosporins is increasing, whereas that of first generation cephalosporins is decreasing gradually. Regarding the class of penicillins, the production of beta-lactam/beta-lactamase inhibitor combinations was the highest after 2003, whereas the production of aminopenicillin was the highest before 2003. Compared to 2003, although the amount of quinolones produced in 2008 has decreased by 52.9%, the cost increased by 41.7%. This was attributed to an increase in the production of ciprofloxacin and levofloxacin instead of older quinolones. Since 1993, aminoglycoside, tetracycline, lincosamide and chloramphenicol have been decreasing in both amount and cost. The increase in carbapenems (241.9%), antifungals (128.4%) and antiviral agents (193.2%) in 2008 is remarkable compared to that in 2003. CONCLUSIONS: The production and cost of broader spectrum and more expensive antibiotics are increasing, and is believed to be responsible for the emergence of resistance. Therefore, restriction of these broader spectrum antibiotics, such as carbapenems, is recommended.